Endoscopic Submucosal Dissection

Podcast Transcript

Dr. Scott Steele: Butts & Guts. A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have our expert guest, Dr. Amit Bhatt here with us who is a gastroenterologist in the Department of Gastroenterology, Hepatology and Nutrition at the Cleveland Clinic and co-director of our Endoluminal Surgery Center. Amit, welcome to Butts & Guts.

Dr. Amit Bhatt: Hey, Scott. Thank you so much for having me here again.

Dr. Scott Steele: So today, we're going to talk a little bit about endoscopic submucosal dissection or what we call ESD. And we'll get into that, but first, tell us a little bit about yourself, about where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Amit Bhatt: Absolutely. So I came to Cleveland actually for my Cleveland Clinic internal medicine training and stayed on for my gastroenterology fellowship, my advanced endoscopy fellowship. And fortunately, thanks to the Cleveland Clinic, I had the opportunity to actually go to Japan and learn about endoscopic submucosal dissection in early cancer during my training. From there, I stayed in Cleveland, stayed at the Cleveland Clinic of Staff, and I'm honored to really co-direct the Endoluminal Surgery Center with my co-director, Dr. Gorgun.

Dr. Scott Steele: So again, as we said today, we're going to talk a little bit about endoscopic submucosal dissection ESD procedure. So to start, give us a little bit of a 10,000-foot view about exactly what ESD is for our listeners.

Dr. Amit Bhatt: Absolutely. So ESD is an endoscopic technique that allows us to remove tumors completely and in one piece from the GI tract. So what does that mean? So an endoscope means that we pass a thin, slim instrument through your mouth or through your bottom and remove lesions from your GI tract being your esophagus, stomach, small bowel, or colon. By removing it endoscopically, patients can avoid surgery. They can keep their native original organs and maintain their quality of life. The specific thing that makes ESD unique is it allows us to precisely remove tumors completely in a very oncologically safe way like a surgeon would do that allows us to achieve curative resection for many of these patients.

Dr. Scott Steele: You mentioned a little bit about malignancy, but give us again a view of what type of lesions exactly are you able to remove using ESD?

Dr. Amit Bhatt: So ESD is very useful for any precancerous or cancerous lesion throughout the GI tract. So the GI tract extends from your mouth to your bottom. And food goes through your esophagus initially to your stomach, to your small bowel, into your colon. In your esophagus, there are esophageal adenocarcinoma or esophageal squamous cell cancer that can develop and if discovered early, we can treat it with ESD. In the stomach, precancerous polyps or even early gastric cancer are removed successfully with ESD. In the small bowel and colon, removing polyps which are precancerous with ESD reduces the risk of reoccurrence and many patients benefit from this at the clinic.

Dr. Scott Steele: So we've had prior guests on that talk a little bit about endoscopic mucosal resection or EMR. So what's the difference between ESD and EMR?

Dr. Amit Bhatt: All these abbreviations. So endoscopy over the years has gone through an evolution. First, we realized that what was removed surgically, we can now sometimes remove from an endoscope. And this first started with hot snare polypectomy putting basically a lasso with electrocautery on it to cut off polyps. Then we realized if we injected fluid underneath the polyp, then we were able to reduce the risk of the procedure and that is what was called endoscopic mucosal resection, where a snare is used to remove a growth from the GI tract, either a cancer or a precancerous polyp. But there was some limitations of this technique. The snare was not very precise and most of the times we had to remove tumors in multiple pieces. And anytime you remove tumors in multiple pieces, there's chances of leaving tumor cells behind, increasing the risk of recurrence, and especially for cancers, it can't be deemed as a curative resection.

The next evolution after EMR came ESD, and that was to solve many of the shortcomings of this EMR technique. In ESD, we use knives to very precisely dissect the margins around the tumor and underneath it. So it allows us to remove a tumor despite how big it is in one complete piece. So tumor cells are not left behind. Our pathologists can confirm the tumor has been completely removed and really, gives patients the best chance of a curative resection.

Dr. Scott Steele: So, give us a little bit of a look behind the curtain. So what exactly do you do during an ESD?

Dr. Amit Bhatt: In principle an ESD, actually, a quite straightforward principle. The GI track is made out of multiple layers, and one of those layers is the submucosa that is made out of loose fibrous tissue. If you inject fluid into this layer, you can actually greatly expand it and have the endoscope enter within the layer and dissect through the submucosal layer. This allows us to remove the tumor that's above the submucosa completely from a patient while allowing them to keep the integrity and organ in place.

Dr. Scott Steele: So unlike in a surgery where you cut out part of the bowel, you're just cutting out part of the lining and you don't cut all the way through.

Dr. Amit Bhatt: Exactly.

Dr. Scott Steele: Fantastic. So truth or myth? Truth or myth? Patients that undergo a endoscopic submucosal dissection spend less time in the hospital compared to those who undergo more traditional surgery.

Dr. Amit Bhatt: Absolutely, Scott. There are many advantages of ESD versus traditional surgery, and one of them is hospital stay. After an endoscopic submucosal dissection is performed, the vast majority of our patients go home that same day. So it is an outpatient procedure and recover quite well from it.

Dr. Scott Steele: So how do you follow those patients and what happens after an ESD procedure? Can they eat right away? Does the lining grow back? I mean, how does all that work?

Dr. Amit Bhatt: I'd love to go over that. So I think this differs by location where it's performed. Obviously, in the upper track where if you eat food, it hits that resection site earlier, there's more restrictions versus later on in the colon there's less restrictions. So for a patient who undergoes endoscopic resection of an esophageal or gastric cancer, we would expect them to have a sore throat and some chest or abdominal discomfort for a few days. There will be some dietary restrictions where they're on three days of liquid diet, three days of soft diet before resuming a normal diet. And the majority of these patients, we see them in clinic two to three weeks after resection and this is to review their pathology and decide on next steps. The majority of these patients are back to their pre resection self with no impact of their quality of life. The reason it's important for us to see them back in two to three weeks is that is when we find the precise histology of the tumor and could really decide what further treatment if necessary needs to be done or can this patient go onto surveillance.

In the colon, we have less restrictions and there's no dietary restrictions after resections, but we don't want these patients to get constipated. So we want of them to stay well hydrated. If they are predisposed to constipation, we recommend daily MiraLAX.

Dr. Scott Steele: So, I'm a patient out there, I'm scheduled to maybe undergoing ESD or some sort of procedure. What questions should I come prepared to ask?

Dr. Amit Bhatt: So first of all, we're very excited that you're coming to do ESD and we're really trying to spread the word that ESD is there and able to help many patients who are going under traditional surgery. But the things that you're really looking for when you're coming in is one is ESD is a technically challenging procedure, and you really want to know that the person and team that are performing it have good experience and a good past outcomes performing it. If you have a esophageal or gastric cancer, these should be treated in a multidisciplinary fashion involving a tumor board and a support of an entire group. So if you are coming in for that, this is not a one-off procedure, but rather a total care. And you want to make sure that that team is there for you.

Dr. Scott Steele: That's fantastic. So are there any advancements on the horizon when it comes to endoscopic submucosal dissection?

Dr. Amit Bhatt: Yes, we're very excited about some technological advances on the way. One of the limitations of ESD is the endoscope was never built for this fine control to do these dissections, and that's what makes it so technically difficult for people to perform it. But on the horizon, probably over the next one to two years, we'll see endoscopic robotic platforms come. In the same way we saw these robotic platforms able to enhance the control in surgery, we're optimistic and look forward to seeing if they can enhance the control in our ability to perform procedures faster and safer in endoscopy. There are still many questions to be answered. For instance, the cost, reimbursement, sort of time for setup, and currently, they're only able to be used in the rectum. But like many new technologies, these questions might be answered as these technological platforms start to be used and we see how they progress.

Dr. Scott Steele: So, Amit, as you mentioned earlier, you and Dr. Emre Gorgun are co-directors of our Endoluminal Surgery Center, which we're blessed to have one of the few, if any, the only one in the nation here at the Cleveland Clinic. So can you tell us a little bit about that?

Dr. Amit Bhatt: We're very fortunate to have the support of our colorectal, our GI and DDSI division to develop an Endoluminal Surgery Center that's really focused on the endoscopic, minimally invasive treatment of early GI neoplasias. My area of specialty or focus is really esophageal, gastric, and duodenal lesions while Emre, my partner focuses on colorectal polyps from below. And this is allowed to streamline combined forces and resources to be really able to take a team approach for the best outcomes for our patients.

Dr. Scott Steele: And that's fantastic. So now, it's time for our quick hitters, a chance to get to know you a little bit better. So first of all, what is your favorite food?

Dr. Amit Bhatt: My favorite food is actually ramen. From my trips to Japan early on, that was the food that I really fell in love there.

Dr. Scott Steele: Any special sauce there or just plain old ramen noodle?

Dr. Amit Bhatt: I had tonkotsu Ippudo ramen. That's good stuff.

Dr. Scott Steele: There we go. There we go. So I'm going to go ahead and go in your car with you and turn on the radio. What's playing?

Dr. Amit Bhatt: Oh, I listened to, wow, such an eclectic group of music. I listen to everything from modern stuff like Halsey to older stuff like Morrissey.

Dr. Scott Steele: Fantastic. So you've traveled the world as you said. So give me something that you would say is still on your bucket list or a trip that is a lasting memory for you.

Dr. Amit Bhatt: Traveling is dear to my heart. I think initially, part of that was for work. We go around, we travel, we give lectures. But now, the greatest joy is my kids love to travel. I have two teenage boys and really, looking forward to taking them around the world and show them what there is. We did a recent trip to Bogotá, Colombia, which I have to admit is a very memorable place and an incredible place to visit.

Dr. Scott Steele: Fantastic. I enjoyed that myself. And so finally, you've been here in Northeast Ohio for quite a bit. So tell us something special about Northeast Ohio.

Dr. Amit Bhatt: It's insidious. It slowly grows on you, and you realize all the benefits that are really not evidently shown from the outside. But this is an incredible place for families, great schools, great nature, outdoor, national parks, golf, tennis. And I could not think of a better place to raise a family.

Dr. Scott Steele: Fantastic. So give us a final take home message regarding ESD for our listeners.

Dr. Amit Bhatt: I think our ability to treat things endoscopically is growing, but many patients are still sent to surgery for early cancers or colon polyps. And I really implore you that many physicians don't know this, or gastroenterologists, or surgeon that really explore yourself to see if ESD or under endoscopic options might be a viable option for your tumor.

Dr. Scott Steele: And that's fantastic. And so to learn more about ESD or to schedule an appointment for treatment at the Cleveland Clinic, please call the ELS, that's Endoluminal Surgery Center at 216.444.3487. That's 216.444.3487. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Bhatt, thanks so much for joining us on Butts & Guts.

Dr. Amit Bhatt: Thank you, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time. Thanks for listening to Butts & Guts.